Early versus late ductal decompression in patiens with acute biliary pancreatitis (ABP) and ampullary obstruction due to impacted gallstone

Introduction: Previous studies suggested that therapeutic window (time from first symptom to ERCP) may determine the final outcome of ABP; and shortening the length of obstruction by early ERCP and EST might reduce the risk of complications. The aim of our present study was to assess the possible relation between the duration of ampullary obstruction and the probability of having complications in patients (pts) who underwent successful ERCP and EST to treat ABP caused by impacted gallstone at the papilla of Vater.

Methods: 53 non-alcoholic pts admitted to our hospital from 2002 to 2008 with ABP associated with impacted gallstones were retrospectively analyzed. In 52 of 53 patients biliary EST was successful to release papillary obstruction. Complete CBD stone clearance achieved in 96% of pts. Overall, at the follow-up there were complications in 11 of 53 pts (19%) and 3 deaths (5.6%). We compared the data of two subgroups: pts with (group I) and without (group II) complications.

Results: The distribution of age and gender were similar in the two subgroups (I. vs. II), 61 vs. 64 years and 28,6% vs. 30,7% male. Interestingly, no significant differences detected between the two groups in the time from initial symptoms to hospital admission, the time from admittance to ERCP, and the time from initial symptom to ERCP: 35+46 vs. 40+42 hours, 7+6 vs. 11+14 hours and 42+47 vs. 51+46 hours, respectively. Significantly higher level of WBC, BUN, CRP were detected in the group I as compared to the group II: 16+7 vs. 12+4 G/L (p<0.05), 12+7 vs. 7+3 (p<0.01), 227+147 vs. 114+91 U/L, respectively (p<0.01). The risk of complications at different therapeutic windows ranged within 24 hs, within 48 hs, and over 48 hs were: 40%, 27% and 22%, respectively.

Conclusions: In a subgroup of ABP pts with impacted gallstone our results suggests that early relief of papillary obstruction with emergency ERCP and EST is not sufficient to prevent all complications. Other technical and patient related factors may influence the outcome in pts with ABP.